Trust of patients and families in mental healthcare providers and institutions: A cross-cultural study in Chennai, India and Montreal, Canada

Purpose: Cross-cultural psychosis research has typically focused on a limited number of outcomes (generally symptom-related). It is unknown if the purported superior outcomes for psychosis in some low- and middle-income countries extend to fundamental treatment processes like trust. Addressing this gap, we studied two similar first-episode psychosis programs in Montreal, Canada and Chennai, India. We hypothesized higher trust in healthcare institutions and providers among patients and families in Chennai at baseline and over follow-up. Methods: Upon treatment entry and at months 3, 12 and 24, trust in healthcare providers was measured using the Wake Forest Trust scale and trust in the healthcare and mental healthcare systems using two single items. Non-parametric tests were performed to compare trust levels across sites and mixed-effects linear regression models to investigate predictors of trust in healthcare providers. Results: The study included 333 patients (Montreal=165, Chennai=168) and 324 family members (Montreal=128, Chennai=168). Across all timepoints, Chennai patients and families had higher trust in healthcare providers and the healthcare and mental healthcare systems. The effect of site on trust in healthcare providers was significant after controlling for sociodemographic characteristics known to impact trust. Patients’ trust in doctors increased over follow-up. Conclusion: This study uniquely focuses on trust as an outcome in psychosis, via a comparative longitudinal analysis of different trust dimensions and predictors, across two geographical settings. The consistent differences in trust levels between sites may be attributable to local cultural values and institutional structures and processes and underpin cross-cultural variations in treatment engagement and outcomes.


Introduction
In the context of healthcare, trust has been understood as stemming from the acceptance of the uncertainty and vulnerability that arises from the illness experience and the belief that one's best interests (as a patient) will be taken care of [1,2]. It has been conceptualized as a multidimensional construct, incorporating aspects such as delity (to the patients' interests above all); competence (both technical and communication-related); honesty; con dentiality; and global trust (an overarching trust component that encompasses more subtle aspects of interpersonal communication) [3]. Components of patients' trust usually pertain to speci c healthcare professionals, but they may also apply to the medical profession as a whole or to healthcare institutions. Interpersonal and institutional dimensions of trust have been reported to be inter-related, despite being considered as different constructs [3][4][5].
Overall, trust is known to be an essential ingredient in therapeutic relationships and considered the foundation of patient-centered care [6]. It is also a major focus of medical ethics [7,8]. Trust in healthcare institutions and healthcare providers have been theorized and found to impact self-reported health, helpseeking, engagement with services and treatment compliance [9][10][11][12][13][14].
Previous studies have reported con icting and at times inconclusive results regarding the association between patients' sociodemographic characteristics and their trust in healthcare institutions and providers [2,15] . When differences between sociodemographic groups were reported, they seemed to lean towards lower trust levels among men, younger and more educated individuals [16][17][18][19][20][21]. Continuity of care and exibility to adapt services to patients' preferences have been reported to enhance trust in different settings [22,23]. Furthermore, issues of communication, partnership and power balance have also been described as impactful for building and preserving trust [24]. Importantly, the way in which these aspects matter to individuals and communities is in uenced by previous experiences, conceptualizations and expectations about healthcare systems and about the nature of patient-provider relationships [25]. These experiences and expectations are in turn largely determined by social and cultural factors and may become particularly salient when comparing different countries [26,27]. Despite the interest in and relevance of exploring and comparing trust in different healthcare settings worldwide, previous studies have paid little attention to trust within healthcare institutions from the Global South. A few extant published studies suggest differences in trust levels and valued aspects of trust between countries [28][29][30][31][32].
Considering the long history of fear and stigma associated with psychiatric institutions and the speci cities of mental health disorders and their treatment, trust building is especially important -and may be particularly challenging -in the context of mental healthcare [21,33,34]. Non-coerciveness, safety, dignity, caring, concern, con dentiality and continuity of care are of distinctive relevance in mental healthcare [35][36][37]. Trust building may be particularly demanding in the provision of care for patients with psychosis [38]. Early intervention for psychosis (EIS), which is the most advocated model of care for rstepisode psychosis [39], emphasizes a patient-centred and recovery-focused approach. These services also place great focus on continuity of care, with patients receiving services throughout their tenure in the program from the same core team (typically, a physician and case manager). However, its simultaneous focus on risk management and medication adherence has been reported to hinder dynamics of trust between patients and providers [40][41][42].
The present study is part of a larger cross-cultural research project [43,44] conducted between 2012 and 2018 in similarly structured EIS, in Montreal (Canada) and Chennai (India). Building from previous (and much disputed) ndings suggesting that psychosis outcomes could be better in economically developing (vs developed) countries [45], the larger study aimed to compare these sites on multiple clinical, subjective and functional outcomes. It also aimed to study core processes (such as service engagement, family involvement and trust) that may be shaped by sociocultural contexts but have rarely been examined in prior cross-cultural psychosis research. These processes are worthy of examination not only because they may underpin inter-site differences in outcomes but also because they are increasingly recognized as valuable in their own right [7,46,47].
In this study, our focus was on differences in the level of trust in healthcare providers among patients and families in Chennai and Montreal. This line of enquiry was sparked by the nding from pilot phase focus groups that patients and family members in Chennai trusted their providers and program more than their engagement and recovery [12,43,44,49], we also deemed it important to assess trust among family members. Likewise, because early intervention services are provided by multidisciplinary teams offering case management and psychiatric follow-up [50], the care providers in whom we measured trust included not only doctors but also case managers.

Aims And Hypotheses
Our primary aim was to compare the trust levels of patients and their family members receiving care at two early intervention services in Chennai and Montreal.
At baseline, we predicted that trust in the medical profession (without reference to any speci c doctor), and in the healthcare and mental healthcare systems (i.e., institutional trust prior to their experience with EIS) would be higher among Chennai patients and families compared to their Montreal counterparts, after accounting for sociodemographic factors associated with trust levels (such as age, gender or educational level) and for institutional trust levels.
At follow-up, we predicted that patients' and families' trust in their doctors and case managers and in the mental healthcare system (now after experiencing care in EIS) would be higher in Chennai than in Montreal, after accounting for sociodemographic factors associated with trust levels (such as age, gender or educational level) and for baseline trust levels.
As exploratory analyses, considering that continuity of care has been previously associated with higher trust levels [35][36][37], we assessed whether trust in doctors and case managers changed over time (from Month 3 to Month 24 of follow-up) at both sites. Finally, acknowledging the relevance of family involvement in the context of early intervention [12,43,44,49], we compared trust between family members and patients.

Setting and sample
This study was conducted in two McGill University-a liated early intervention services in Montreal, Canada (Prevention and Early Intervention Program for Psychosis/PEPP), and one early intervention service in Chennai, India (Schizophrenia Research Foundation/SCARF). PEPP is a publicly funded program that is part of the healthcare system and SCARF is a non-governmental non-pro t organization and a World Health Organization (WHO) collaborating center. Both programs follow international guidelines for early intervention services [51][52][53], work on an open-referral basis and offer services that focus on early, assertive, phase-speci c and recovery-oriented care [54,55]. At both programs, patients are followed for two years by a multidisciplinary team and receive a wide range of psychosocial and medical services including assertive case management, family psychoeducation, exible use of antipsychotic medication and, as needed, other individual and family psychosocial interventions. Although both programs share many commonalities, some adaptations were made to the Indian context, including a more exible access to services (e.g., services provided without an appointment or by phone), the implementation of home-based interventions such as cognitive training focused on household chores, and a particular emphasis on family involvement [55].

Inclusion criteria
Primary diagnosis of a schizophrenia-spectrum or affective psychotic disorder (DSM-IV classi cation) Age between 16-35 years old Ability to communicate in Tamil or English (Chennai) and in French or English (Montreal).

Exclusion criteria
Treatment with antipsychotic medication for more than one month Primary diagnosis of a pervasive developmental disorder, organic psychosis or substance abuse/dependence. Patients with concurrent diagnoses of substance abuse/dependence were not excluded.

IQ below 70
Family members recruited for this study included parents, legal guardians, grandparents, siblings, spouses/partners, extended family members, friends and roommates.

Measures
Assessments were administered by staff who went through similar training, using measures that had been previously administered at both study sites [48]. Several measures were taken to ensure quality of assessments, including inter-rater reliability sessions and centralized data management and veri cation. Patients' and family members' sociodemographic data were assessed at baseline through a questionnaire developed speci cally for the larger study.
Interpersonal trust levels were measured using the Wake Forest Trust in Medical Profession Scale and the Wake Forest Physician Trust Scale [2, 56] (suppl. table 1). Both are short 5-item forms, assessing selfreported trust in the medical profession or towards a speci c physician, respectively. For the purpose of this study, the Wake Forest Physician Trust Scale was also modi ed to assess trust in case managers and to be administered to family members. Although the Wake Forest Trust scales have not been extensively used in the context of mental healthcare [57], they were chosen for their demonstrated adequate psychometric properties, brevity and simplicity [56]. Permission for adaptation and translation was sought from the lead developers of these instruments. All scales were translated from English into Tamil and French and back-translated using standardized procedures recommended for cross-cultural research [58-60]. Each item of the scales is scored from 1 (strongly disagree) to 7 (strongly agree), with higher scores indicating higher trust.
Institutional trust was measured with two self-rated items, one to assess trust in the healthcare system (How much do you trust the health care system?) and the other to assess trust in the mental healthcare systems (How much do you trust the mental health care system?). While the former has been applied in previous studies [14,61], the latter was created for this study. These questions are scored from 1 (no trust at all) to 5 (very high trust).
We evaluated the psychometric properties of the modi ed Wake Forest scales and the single self-rated item on trust in the mental healthcare system. Overall, we found that reliability and internal consistency estimates were adequate for patients and families, in Montreal and Chennai (suppl. table 2).
Patients and family members completed the trust measures at different time points. At baseline (entry into the early intervention service), the self-reported trust measures included the Wake Forest Trust in Medical Profession Scale and the two additional questions on institutional trust (speci cally, trust in the healthcare system and in the mental healthcare system). During follow-up (at months 3, 12 and 24 after baseline), the Wake Forest Physician Trust Scale, its adapted version for case managers and the singleitem questionnaire on trust in the mental healthcare system were distributed.

Data analysis
As different trust measures were administered at baseline and during follow up, data analysis was performed both cross-sectionally and longitudinally. Descriptive data were presented using proportions for categorical variables and means, standard deviations, medians and IQRs (interquartile ranges) for continuous variables. Total scores from 5-item trust scales were standardized to a scale from 1 to 5 to facilitate comparisons. Chi-square statistics were performed to examine differences between sites regarding categorical variables and t-tests were computed to assess site differences for continuous and normally distributed sociodemographic variables. To assess whether continuous sociodemographic variables were associated with trust measures, Spearman correlations were used, due to the right skewness of the trust data. In order to analyse differences in trust levels between sites and stakeholder groups, non-parametric Mann-Whitney tests were performed. Effect sizes were calculated using eta squared ( p 2 ) coe cients, classi ed as small: ( 2 = 0.01), medium ( 2 = 0.06) and large ( 2 = 0.14) [62].
Linear regression models were tted to assess predictors of trust in the medical profession at baseline and linear mixed effects models (autoregressive covariance structure) were tted to assess predictors of trust in doctors and trust in case managers during follow-up (months 3, 12 and 24). Independent variables were chosen based on study hypotheses. The choice of models was based on theoretical The total baseline sample included 333 patients with rst-episode psychosis from Montreal (N = 165) and Chennai (N= 168), and 324 family members from Montreal (N=128) and Chennai (N=168). At baseline, at both sites, most patients were in their mid-twenties, had completed high school level education and lived with their families. Participants from Montreal were signi cantly younger, more often male and single. Most family members belonged to the age group between 50-60 years old, were female, patients' parents, and had high school (or higher) education. Family members from Chennai were more likely to be female, to have less than high school education and to be older than Montreal family members (table 1).

Comparison of trust levels between sites
At baseline, patients and family members in Chennai had higher trust in the medical profession, and in the healthcare and mental healthcare institutions, compared to participants in Montreal (table 2). Similarly, during follow-up, both patients and family members in Chennai had higher trust in their doctors, case managers, and in the mental healthcare system, compared to their counterparts in Montreal (table   3).

Comparison between stakeholders
At baseline, in Chennai, families had higher trust in the medical profession and in institutions (healthcare and the mental healthcare system) compared to patients. In Montreal, no statistically signi cant differences were found between patients' and families' trust levels in institutions and in the medical profession (table 4). During follow-up, differences between stakeholders were often statistically signi cant (across different timepoints) in Chennai, with families scoring higher than patients in all trust measures at month 12 and 24. In contrast, no signi cant differences were found between patients' and family members' levels of trust in Montreal, at months 3 and 12. When differences were found (at month 24), patients showed higher trust than family members in both doctors and the mental healthcare system (table 5).

Discussion
As hypothesized, compared to their counterparts in Montreal, both patients and family members from Chennai scored higher on all self-reported measures of institutional trust (in the healthcare and mental healthcare systems) and interpersonal trust (in the medical profession at baseline and in their own doctor and case manager during follow-up). The effect of site was still signi cant even when other variables (such as age, gender, educational level), known to in uence trust, were added to the models.
Site differences in trust are likely to be in uenced by the social, cultural and political contexts that underpin peoples' realities at both sites (Montreal and Chennai). Sociocultural contexts also shape public opinion and determine previous experiences with healthcare services and providers by in uencing the availability, access and quality of services received. All in all, contexts mould expectations regarding institutions and healthcare professionals, shaping the ways in which therapeutic relationships are conceptualized and enacted in the context of healthcare [25,64,65]. Previous studies have also identi ed differences in institutional [27] and interpersonal [26] trust between countries. Such differences have been attributed to distinct local cultural values (thought to favour or hinder trust as a general societal value), and to structural differences in healthcare systems in terms of availability, affordability and quality of services.
It has been suggested that trust may be higher in collectivistic (than in individualistic) societies, characterized by a higher sense of group and interpersonal cooperation, greater emphasis on hierarchy and authority, and less concern with avoiding uncertainty. Our study results align with this perspective, since Canada and India could arguably be placed at the opposite poles of the individualistic-collectivistic spectrum [66][67][68]. However, care should be taken when applying such classi cations in a simplistic fashion, as cultural value orientations are not generalizable to whole populations and may differ substantially from individual-level and intra-society values. Moreover, in India, where cultural values seem to favour higher trust as a general value, it has been reported that trust towards others, the government and science is low, as compared to individualistic societies [69]. Likewise, accounts of low trust towards health institutions have been reported in India [70]. It may also be that the trust that participants in Chennai placed in the mental healthcare/healthcare systems and care providers was driven by the setting of this study being SCARF, which is an esteemed NGO valued by the local community for its free highquality services [71]. Similar levels of high trust in other healthcare systems and providers may not be evident in the Indian populace. A similar argument could be made about PEPP, where relatively high trust levels were also reported. Both PEPP and SCARF's early intervention services were built under a care model that was initiated to break with previous practices by facilitating access, promoting engagement and providing individualized and stage-speci c treatment. However, such services might stand out more in a context like India where resources are limited and where a universal public healthcare system is not implemented [70,72].
At baseline, trust in the medical profession was associated with trust in the healthcare and mental healthcare system, for both patients and family members. Age was a signi cant predictor of trust for only family members, with older individuals having higher trust levels, as previously reported in the literature [16][17][18][19][20][21], suggesting a generational effect that could be partly related with previous healthcare experiences. Patients' and families' trust in the medical profession at baseline predicted their trust in their doctors (and case managers) over the course of follow-up. This nding is aligned with previous studies reporting a positive correlation between public trust in doctors and trust in speci c physicians [3].
When comparing stakeholder groups, results differed by site, with family members from Chennai reporting consistently higher trust levels in both institutions and healthcare providers. In Montreal, however, no differences were found between patients' and families' trust levels, at most timepoints. This is particularly relevant given that in other studies from this cross-cultural project, family involvement was found to be higher in Chennai than in Montreal, and valuable for both promoting engagement and better clinical outcomes [43,44].
This study has several strengths, which include its prospective design and well-de ned inclusion and exclusion criteria, the similarity of the care models and protocols at both sites, the rigorous staff training, centralized data management and veri cation, and the strong psychometric properties of the instruments used. Furthermore, it is unique and innovative in its focus on trust in early intervention services for psychosis, while assessing trust across countries in a nuanced way, considering different trust dimensions (interpersonal and institutional), from different points of view (i.e., from patient and family member perspectives). Several study limitations should also be noted. At both sites, all stakeholders reported high levels of institutional and interpersonal trust, with medians ranging between 3.4 and 5 (out of a total of 5 points), suggesting that responses could have been in uenced to some extent by social desirability. However, both families and patients were asked to report their trust levels at an early stage of contact with services. Also, all trust scales showed good to excellent psychometric properties at both study sites. It should also be pointed out that not all chosen measures were developed speci cally for this study and hence were not speci cally adapted to the study populations who could conceptualize and evaluate trust differently. For instance, previous studies from South India have reported that, for doctors to be trusted, it is more important that patients experience respect, loyalty, comfort, personal involvement by the care provider, cultural competence and the assurance of being treated (regardless of the ability to pay), whereas the experience of individuality, shared responsibility and con dentiality tend to be emphasized in Western contexts [32,[73][74][75]. Furthermore, the validity of the institutional trust measures could be questioned in the Indian context, since evaluating systems may be a di cult task when there are no clear systems in place. Nonetheless, both the questions regarding institutional trust and the Wake Forest trust scales (and adaptations) are general and focused on aspects of trust that are relevant at both settings (e.g.: overall trustworthiness of care-provider/institution; subjective competence; careful and attentive behaviour by the care-provider). A considerably higher number of participants from Montreal did not complete the trust scales at baseline. Even though there were no differences (in terms of the assessed demographic variables) between responders and non-responders for both patients and family members, we cannot exclude the possibility that the non-responders would have reported lower (or higher) trust levels. If so, site differences may have been underestimated (or overestimated). Of note, differential response rates may be re ective of contextual differential engagement with services [43], which in turn may be underpinned by contextually and culturally shaped notions of trust [66]. Site differences are likely to re ect the impact of a very complex array of factors that we have only partially accounted for in this study. Trust is a two-way street and, in this study, we have not measured care provider attitudes that could differ between sites and that may hinder or facilitate trust. Finally, future studies examining trust in crosscultural contexts would bene t from including additional variables known to in uence trust and which may differ between sites. Some examples would be the assessment of care provider attitudes and institutions' attributes, self-assessment of stigma and self-stigma (reported to negatively impact trust) [21] and of aspects of pathways to care that might impact trust (e.g.: police involvement, etc.) [76].
Further studies set to qualitatively explore the reasons and mechanisms underlying site differences in trust could be particularly enlightening and result in a more ne-grained understanding about what trust means, what contributes to it and what it implies for patients, family members and clinicians across contexts.